III. Pathophysiology

  1. General
    1. Vascular related focal cerebral dysfunction
    2. Acute Neurologic Syndrome is analogous to Acute Coronary Syndrome
      1. Coronary syndrome evaluation is differentiating Myocardial Ischemia from infarction with Troponin
      2. Acute Neurologic Syndrome evaluation is differentiating cerebral ischemia from infarction with Brain MRI
  2. Spectrum
    1. Acute Neurologic Syndrome or Transient Ischemic Attack (TIA)
      1. Temporary neurologic dysfunction
        1. Focal cerebral ischemia or
        2. Focal spinal ischemia or
        3. Retinal ischemia
      2. No Cerebral Infarction (based on imaging)
        1. Previously defined as duration less than 24 hours (usually <10 minutes)
    2. Cerebral Infarction with Transient Signs (CITS)
      1. Partially reversible, non-disabling stroke (minor stroke)
    3. Ischemic Cerebrovascular Accident
      1. Non-reversible stroke

V. Risk Factors

VI. Precautions

  1. Urgently evaluate new onset TIA within hours to days
    1. See Prognosis below for studies regarding risk
    2. Stroke follows TIA within 90 days in 20-25% of cases
    3. Odds Ratio for Stroke following TIA
      1. At 1 month: 30.4 Odds Ratio
      2. At 1-3 months: 18.9 Odds Ratio
      3. At 4-6 months: 3.16 Odds Ratio
      4. After 5 years: 1.87 Odds Ratio
      5. Thacker (2010) Stroke 41(2): 239-43

VII. Evaluation

  1. History
    1. Obtain history from witnesses who observed episode
    2. Evaluate differential diagnosis (see Ischemic CVA)
    3. Evaluate TIA Risk Factors
    4. Determine anterior or posterior circulation (above)
    5. Determine probable source (see causes above)
    6. Ask about conditions associated with TIA mimics (conditions on differential diagnosis)
      1. Cognitive disorder
      2. Seizure Disorder
      3. Postural Hypotension
      4. Vertigo
  2. Examination
    1. Thorough cardiovascular examination
      1. Assess for Carotid Bruit
      2. Funduscopic Examination
      3. Assess for Atrial Fibrillation
      4. Assess for Heart Murmur
      5. Assess for Hypertension
        1. CVA commonly presents with Hypertension
    2. Thorough Neurologic Examination
      1. Often normal if TIA has completely resolved
      2. See Neurologic Exam
      3. See NIH Stroke Scale

VIII. Symptoms

  1. Symptoms most suggestive of TIA or CVA
    1. Sudden onset
    2. Recurrent focal symptoms (higher risk for future CVA)
    3. Diplopia
    4. Transient Monocular Blindness
    5. Unilateral paresis (Hemiparesis)
    6. Speech disturbance (Dysarthria)
  2. Symptoms most suggestive of alternative diagnosis (TIA mimic or non-TIA)
    1. Precaution
      1. Presence of these symptoms does not exclude TIA
      2. These symptoms are still present in TIAs, but at a lower percentage than in TIA mimics
    2. Most suggestive of mimic over TIA
      1. Gradual onset of symptoms
      2. Non-specific neurologic symptoms
        1. Memory loss or amnesia
        2. Headache
        3. Blurred vision
    3. Other findings more suggestive of mimic than TIA (if isolated symptom or sign)
      1. Generalized weakness
      2. Dizziness (especially if not Vertigo)
      3. Confusion
      4. Loss of consciousness
      5. Tinnitus
      6. Dysphagia
      7. Scintillating Scotoma
      8. Headache
      9. Eye Pain
      10. Chest Pain
      11. Drop attacks (sudden spontaneous fall)

IX. Signs

  1. Findings most suggestive of TIA or CVA
    1. Unilateral motor weakness
      1. May be associated with spasticity, Clonus or rigidity
    2. Speech deficits
  2. Cranial Nerve deficits: General
    1. Facial drooping
    2. Lateral Tongue movement
    3. Dysphagia
  3. Cranial Nerve deficits: Vision
    1. Diplopia
    2. Hemianopia
    3. Monocular blindness
    4. Disconjugate gaze
  4. Cerebellar deficits and vestibular dysfunction
    1. Ataxia
    2. Nystagmus

X. Symptoms and Signs: Localizing findings

  1. Timing
    1. Carotid TIAs resolve within 14 minutes
    2. Vertebral TIA resolve within 8 minutes
    3. Symptoms persisting >1 hour: 2-14% resolve in 24 hours
    4. Albers (2002) N Engl J Med 347(21):1713-6
  2. Anterior circulation symptoms (Carotid Artery)
    1. See Anterior Cerebral Artery CVA
    2. See Middle Cerebral Artery CVA
    3. Transient Monocular Blindness (Amaurosis Fugax)
    4. Clumsiness, weakness or numbness of hand
    5. Speech changes
  3. Posterior circulation symptoms (Vertebro-basilar)
    1. See Posterior Inferior Cerebellar Artery CVA
    2. See Vertebro-Basilar CVA
    3. See Posterior Cerebral Artery CVA
    4. Binocular vision changes or Diplopia
    5. Vertigo, ataxia or light headedness
    6. Dysarthria
    7. Generalized weakness
    8. Loss of consciousness
    9. Transient global amnesia

XI. Labs

  1. Initial
    1. Complete Blood Count (CBC)
    2. Serum Glucose
      1. Urgent bedside, finger stick Glucose on presentation
    3. Serum electrolytes
    4. ProTime with INR
    5. Partial Thromboplastin Time (aPTT)
  2. Labs during admission or outpatient
    1. Fasting Serum Lipids
    2. Serum Vitamin B12
  3. Other labs to consider in young patients (age <50 years)
    1. See Hypercoagulable for clotting predisposition evaluation
    2. See Altered Level of Consciousness for evaluation
    3. Lumbar Puncture
      1. Evaluate for CNS Infection (Meningitis or Encephalitis)
    4. Urine Drug Screen
    5. Blood Alcohol level
    6. Rapid plasmin reagin (RPR for Syphilis)

XII. Imaging: First Line Evaluation (emergent, immediate)

  1. Head CT
    1. Head CT is the recommended study in acute CVA if Thrombolysis is being considered
    2. Identifies prior infarction or Hemorrhagic CVA
    3. Identifies Brain Tumor and other CNS masses

XIII. Imaging: Second Line Evaluation

  1. Typical evaluation in first 24-48 hours
    1. MRI Brain
      1. Patients presenting with TIA and demonstrate infarction on MRI have a 20% chance of in-hospital CVA
      2. Ay (2005) Ann Neurol 57(5): 679-86
    2. Magnetic Resonance Angiography (MRA) of Brain and Neck
    3. Transthoracic Echocardiogram
      1. Consider Transesophageal Echocardiogram if emboli suspected and negative echo
      2. Primary conditions to identify in TIA cases
        1. Cardioembolic source
        2. Patent Foramen Ovale
        3. Valvular heart disease
  2. Studies to consider on discharge
    1. Holter Monitor
      1. Identify suspected intermittent Atrial Fibrillation and not found on inpatient telemetry
  3. Other studies
    1. Carotid Ultrasound for anterior circulation (or MRA Neck)
      1. MRA Neck has largely replaced carotid Ultrasound in post-CVA assessment
      2. Carotid Ultrasound is a good alternative when dictated by expense or MRI contraindications
      3. Carotid Stenosis <50% suggests other source
      4. Carotid Stenosis >50% (especially if >80%)
        1. Obtain carotid arteriogram or MRA
        2. Arteriogram or MRA confirms >70% stenosis: Surgery
        3. Arteriogram or MRA suggests 50-69% stenosis
          1. Consider surgery in lower risk patient
          2. Medical therapy in high risk patient
    2. Transcranial Ultrasound for posterior circulation
    3. Arteriography
      1. Gold standard for pre-endarterectomy evaluation

XIV. Differential Diagnosis

  1. See Ischemic CVA
  2. Findings making TIA mimic more likely
    1. See symptoms above
    2. See history above
  3. Common TIA mimics (alternative diagnoses)
    1. Metabolic disturbance (e.g. Hypoglycemia)
      1. Hypoglycemia is always considered but is not expected to resolve spontaneously as in a TIA without intervention
    2. Complicated Migraine Headache (including aura)
    3. Seizure disorder (including post-ictal period)
      1. May present with Todd's paralysis
    4. Syncope
      1. Syncope is a a global hypoperfusion event
      2. Acute Neurologic Syndrome (Tranient Ischemic Attack) is a loss of a neurologic function
  4. Other alternative diagnoses
    1. CNS tumor
    2. CNS Infection (Meningitis, Encephalitis)
    3. Multiple Sclerosis
    4. Subarachnoid Hemorrhage
    5. Vertigo

XV. Management

  1. See Risk Factor Modification Following Transient Ischemic Attack
  2. Early diagnosis and risk factor management can recurrent Ischemic CVA by as much as 80%
    1. Rothwell (2007) Lancet 370(9596): 1432-42
  3. Immediate management of suspected TIA
    1. Start Aspirin 81 to 325 mg orally daily
      1. Do not start until CT Head negative for Hemorrhage
    2. Do not lower Blood Pressure acutely in most cases
      1. See CVA Blood Pressure Control for special circumstances
    3. ER evaluation if symptom onset <48 hours ago
      1. See labs and radiology above
      2. See CVA Management if ongoing symptoms
        1. Consider for Thrombolytic management in CVA (if persistent significant deficit meeting criteria)
    4. Urgent outpatient evaluation if >48 hours
      1. See labs and radiology above
      2. See Carotid Stenosis for Endarterectomy Indications
      3. See Prevention of Ischemic Stroke
  4. Inpatient evaluation criteria
    1. ABCD2 Score-based criteria
      1. ABCD2 Score: 5 or higher
      2. ABCD2 Score: 4 and
        1. MRA head and neck with symptomatic lesion
      3. ABCD2 Score: 3 and
        1. Symptoms resolved within prior 72 hours and
        2. Focal ischemia signs and
        3. Neurovascular imaging not available (e.g. MRA)
      4. References
        1. Olivot (2011) Stroke 42(7): 1839-43
    2. Cardioembolic source with Anticoagulation considered
      1. Acute MI with large wall motion abnormality
    3. Large or evolving Cerebrovascular Accident
      1. Severe neurologic deficit (e.g. dense Hemiplegia)
      2. TIA symptoms recurring at increasing frequency
    4. Vascular or neurosurgery Consultation may be required
      1. High grade Carotid Stenosis suspected
      2. Possible Subarachnoid Hemorrhage
    5. High risk for CVA or TIA complications
      1. Aspiration Pneumonia

XVI. Precautions

  1. Transient Ischemic Attacks are not outpatient problems (evaluate in emergency or inpatient setting)
  2. Evaluate and manage TIA underlying causes (e.g. Carotid Stenosis) within 2 weeks of event

XVII. Prevention

  1. See Carotid Stenosis for Endarterectomy Indications
  2. See Prevention of Ischemic Stroke

XVIII. Prognosis

  1. Risk of Cerebrovascular Accident within 2 days of Acute Neurologic Syndrome (Transient Ischemic Attack)
    1. See ABCD2 Score
  2. Adverse events occur in 20-25% with TIA within 90 days
    1. CVA represents 10% of these adverse events
    2. 50% of CVAs occurred within 2 days of TIA
  3. References
    1. Coull (2004) BMJ 328:326-8
    2. Johnston (2000) JAMA 284:2901-6

Images: Related links to external sites (from Google)

Ontology: Transient Ischemic Attack (C0007787)

Definition (NCI) A brief attack (from a few minutes to an hour) of cerebral dysfunction of vascular origin, with no persistent neurological deficit.
Definition (NCI) A disorder characterized by a brief attack (less than 24 hours) of cerebral dysfunction of vascular origin, with no persistent neurological deficit.
Definition (CHV) mini stroke which is recoverable
Definition (CHV) mini stroke which is recoverable
Definition (CHV) mini stroke which is recoverable
Definition (CHV) mini stroke which is recoverable
Definition (CHV) mini stroke which is recoverable
Definition (CHV) mini stroke which is recoverable
Definition (CHV) mini stroke which is recoverable
Definition (CHV) mini stroke which is recoverable
Definition (CHV) mini stroke which is recoverable
Definition (CHV) mini stroke which is recoverable
Definition (CHV) mini stroke which is recoverable
Definition (CHV) mini stroke which is recoverable
Definition (MEDLINEPLUS)

A transient ischemic attack (TIA) is a stroke that comes and goes quickly. It happens when a blood clot blocks a blood vessel in your brain. This causes the blood supply to the brain to stop briefly. Symptoms of a TIA are like other stroke symptoms, but do not last as long. They happen suddenly, and include

  • Numbness or weakness, especially on one side of the body
  • Confusion or trouble speaking or understanding speech
  • Trouble seeing in one or both eyes
  • Loss of balance or coordination

Most symptoms of a TIA disappear within an hour, although they may last for up to 24 hours. Because you cannot tell if these symptoms are from a TIA or a stroke, you should get to the hospital quickly.

TIAs are often a warning sign for future strokes. Taking medicine, such as blood thinners, may reduce your risk of a stroke. Your doctor might also recommend surgery.

NIH: National Institute of Neurological Disorders and Stroke

Definition (MSH) Brief reversible episodes of focal, nonconvulsive ischemic dysfunction of the brain having a duration of less than 24 hours, and usually less than one hour, caused by transient thrombotic or embolic blood vessel occlusion or stenosis. Events may be classified by arterial distribution, temporal pattern, or etiology (e.g., embolic vs. thrombotic). (From Adams et al., Principles of Neurology, 6th ed, pp814-6)
Definition (CSP) recurring, transient episodes of neurologic dysfunction caused by cerebral ischemia; onset is usually sudden, often when the patient is active; the attack may last a few seconds to several hours; neurologic symptoms depend on the artery involved.
Definition (NCI) A brief attack (from a few minutes to an hour) of cerebral dysfunction of vascular origin, with no persistent neurological deficit.
Concepts Disease or Syndrome (T047)
MSH D002546
ICD10 G45.9
SnomedCT 313242003, 195207009, 38609002, 266257000, 155404005, 195196001, 266314007
English T.I.A., Temporary cerebral dysfunction, vascular, Attacks, Transient Ischemic, Ischemic Attack, Transient, Ischemic Attacks, Transient, Transient Ischemic Attack, Transient Ischemic Attacks, Attack, Transient Ischemic, STROKE, TEMPORARY, TRANSIENT ISCHEMIC ATTACKS, TIA - Transient ischaem attack, TIA - Transient ischemic attack, Transient cerebral ischaemic attack, unspecified, Transient cerebral ischemic attack, unspecified, TRANSIENT ISCHAEMIC ATTACK, Transient ischemic attacks (disorder), transient cerebral ischemic attack, tia, tias, Transient cerebral ischaemia NOS (disorder), Transient cerebral ischemia (disorder), transient ischemic attack (diagnosis), transient ischemic attack (TIA), transient ischemic attack, Transient ischaemic attacks, Transient ischemic attacks, TIA (Transient Ischemic Attack), Brain TIA, TIA, Brain, ATTACK, TRANSIENT ISCHEMIC, ISCHEMIC ATTACK, TRANSIENT, TRANSIENT ISCHEMIC ATTACK, Ischemic Attack, Transient [Disease/Finding], transient cerebral ischemia, transient ischaemic attacks, brain tia, tia brain, attack ischemic transient, ischemic attack transient, attacks ischemic transient, transient ischemic attacks, TIAs (Transient Ischemic Attack), Transient cerebral ischemia, TIA, Transient ischemic attack, Temporary cerebral vascular dysfunction, TIA - Transient ischaemic attack, Transient cerebral ischaemia, Transient ischaemic attack, Transient ischemic attack (disorder), attack; transient, transient; attack, Transient cerebral ischemia, NOS, Transient cerebral ischaemia NOS, Transient cerebral ischemia NOS, Transient cerebral ischaemia, NOS, Transient cerebral ischemia (disorder) [Ambiguous], transient ischaemic attack
Dutch transient ischaemic attacks, attack; transient, transient; attack, 'Transient (cerebral) ischaemic attack' [TIA], niet gespecificeerd, transient ischaemic attack, Attack, transient ischaemic (TIA), Ischaemic attack, transient (TIA), TIA, Transient ischaemic attack (TIA)
French AIT, Accidents ischémiques transitoires, Accident ischémique cérébral transitoire, Accident ischémique transitoire, ACCIDENT ISCHEMIQUE TRANSITOIRE, AIT (Accident Ischémique Transitoire), Accidents ischémiques cérébraux transitoires, Accès ischémique transitoire cérébral, Accès ischémiques transitoires cérébraux
German transitorische ischaemische Attacken, Zerebrale transitorische ischaemische Attacke, nicht naeher bezeichnet, transitorische ischaemische Attacke, TIA, Ischämische Attacke, transitorische, Transitorisch-ischämische Attacken
Italian Attacchi ischemici transitori, TIA (Attacco ischemico transitorio), Attacco ischemico transitorio
Portuguese Ataques isquémicos transitórios, AIT, ACIDENTE ISQUEMICO TRANSITORIO, Isquemia do Tronco Encefálico Transitória, TIA, Acidente isquémico transitório, Ataque Isquêmico Transitório
Spanish Accidentes isquémicos transitorios, Transient ischemic attack, Transient ischaemic attack, ataques isquémicos transitorios, ataques isquémicos transitorios (trastorno), Transient cerebral ischemia, Transient ischemic attacks, Transient cerebral ischaemia, Transient cerebral ischaemia NOS, Transient ischaemic attacks, Isquemia del Tronco Encefálico Transitoria, TIA, Isquemia del Tronco Encefalico Transitoria, isquemia cerebral transitoria, SAI (trastorno), Transient cerebral ischemia NOS, isquemia cerebral transitoria, SAI, AIT, accidente isquémico transitorio (concepto no activo), accidente isquémico transitorio (trastorno), accidente isquémico transitorio, ataque isquémico transitorio (trastorno), ataque isquémico transitorio, disfunción vascular cerebral temporal, isquemia cerebral transitoria, Accidente isquémico transitorio, Ataque Isquémico Transitorio, Ataque Isquemico Transitorio
Swedish Hjärnischemi, övergående
Japanese イッカセイノウキョケツホッサ, TIA, TIA, 漸強性一過性脳虚血発作, 脳幹虚血-一過性, 可逆的虚血性神経性欠損, 脳虚血発作-一過性, 回復性虚血性神経脱落徴候, 可逆的虚血性神経障害, 一過性脳虚血, 一過性脳虚血発作, 一過性脳幹虚血, 脳虚血-一過性
Finnish Ohimenevä aivoverenkiertohäiriö
Russian ISHEMIIA MOZGA TRANZITORNAIA, MOZGA GOLOVNOGO ISHEMIIA TRANZITORNAIA, STVOLA MOZGA ISHEMIIA TRANZITORNAIA, TSEREBRAL'NAIA ISHEMIIA TRANZITORNAIA, MOZGA GOLOVNOGO ISHEMICHESKAIA ATAKA TRANZITORNAIA, NARUSHENIE MOZGOVOGO KROVOOBRASHCHENIIA TRANZITORNOE, ИШЕМИЯ МОЗГА ТРАНЗИТОРНАЯ, МОЗГА ГОЛОВНОГО ИШЕМИЧЕСКАЯ АТАКА ТРАНЗИТОРНАЯ, МОЗГА ГОЛОВНОГО ИШЕМИЯ ТРАНЗИТОРНАЯ, НАРУШЕНИЕ МОЗГОВОГО КРОВООБРАЩЕНИЯ ТРАНЗИТОРНОЕ, СТВОЛА МОЗГА ИШЕМИЯ ТРАНЗИТОРНАЯ, ЦЕРЕБРАЛЬНАЯ ИШЕМИЯ ТРАНЗИТОРНАЯ
Czech Tranzitorní ischemické ataky, Tranzitorní ischemická ataka, mozek - ischémie tranzitorní, TIA, přechodná mozková ischémie, mozek - ischémie přechodná, uzávěr a zúžení mozkových tepen nekončící mozkovým infarktem, tranzitorní ischemická příhoda, tranzitorní ischemická ataka
Korean 상세불명의 일과성 대뇌 허혈성 발작
Croatian ISHEMIJSKI MOŽDANI UDAR, PROLAZNI
Polish Miniudar mózgu, Przemijający epizod niedokrwienia mózgu, TIA, Napad przemijającego niedokrwienia mózgu, Incydent przemijającego niedokrwienia mózgu, Przemijające objawy ubytkowe, Przejściowy atak niedokrwienny, Przemijający napad niedokrwienny mózgu
Hungarian Transiens ischaemiás attack, Átmeneti ischaemiás rohamok, TIA

Ontology: Reversible ischemic neurologic deficit (R.I.N.D.) syndrome (C0553690)

Concepts Disease or Syndrome (T047)
SnomedCT 36179005, 38609002
Italian Deficit neurologico ischemico reversibile
English RIND-Reves isch neurol defec, Revers isch neurologic defec, R.I.N.D. syndrome (disorder), Reversible ischaemic neurologic deficit (R.I.N.D.) syndrome, Reversible ischemic neurologic deficit (R.I.N.D.) syndrome (disorder), Reversible ischemic neurologic deficit (R.I.N.D.) syndrome, reversible ischemic neurologic deficit (diagnosis), reversible ischemic neurological deficit, rind, reversible ischemic neurologic deficit, RIND syndrome, REVERSIBLE ISCHEMIC NEUROLOGIC DEFICIT, RIND, reversible ischemic neurologic deficit (R.I.N.D.) syndrome, Reversible ischaemic neurological deficit, Reversible ischemic neurological deficit, R.I.N.D. syndrome, Reversible ischemic neurologic deficit syndrome, RIND - Reversible ischaemic neurological defect, RIND - Reversible ischemic neurological defect, Reversible ischaemic neurologic deficit syndrome, Reversible ischaemic neurological defect, Reversible ischemic neurological defect
Dutch reversible ischemic neurological deficit, reversibel ischemisch neurologisch defect
Portuguese Défice neurológico isquémico reversível, Défice isquémico neurológico reversível
Japanese 回復性虚血性神経脱落症候, カイフクセイキョケツセイシンケイダツラクショウコウ
Czech Reverzibilní ischemický neurologický deficit
Hungarian Reversibilis ischaemiás neurológiai deficit, Reverzibilis ischaemiás neurológiai deficit
Spanish síndrome de déficit neurológico isquémico reversible (trastorno), síndrome de déficit neurológico isquémico reversible, Déficit neurológico isquémico reversible, síndrome D.N.I.R., síndrome R.I.N.D.
French Déficit neurologique ischémique réversible
German reversible ischaemische neurologische Stoerung